Shadowed an em doc yesterday. 4 rectals in 12 hours. He said that was about avg. Not sure I can do that every day.

Who should I shadow next to restore my motivation? Derm?

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Dude, nothing is more disgusting than a serious skin rash except maybe childbirth, and some skin infections smell bad enough to bring tears to your eyes.

Seriously, though, almost all of medicine is gross. If you go into any clinical specialty where you deal with patients (not just EM), you are going to have to see and smell parts of the body you'd probably rather not. If that bothers you, medicine might not be the best career choice.

Untrue and uninformed--I don't like doing them either but there are clear medical indications for the exam

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Sure there are. But on everyone with an anus? I think not. My point is it's probably done more than it needs to be. And i would rather do a dre anyday rather than a pelvic. Any evidence to support the widespread use of them and I will gladly retract my statement.

Sure there are. But on everyone with an anus? I think not. My point is it's probably done more than it needs to be. And i would rather do a dre anyday rather than a pelvic. Any evidence to support the widespread use of them and I will gladly retract my statement.

And the idea of using a swab? I'd rather have a lubed, gloved finger used instead of some swab that could break off inside and puncture the rectum.

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I almost never do them. There is very little that is going to change by exam. If someone has a complaint of rectal pain, I'll take a look externally and see if there is a fissure or hemorrhoid. If they are stable and not bleeding profusely, then can follow up with a GI doctor.

So, we should just keep them in the ER until they have their daily BM? I think administration would be a little upset about the length of stay if we did that.

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Ha, whats the average length of stay now? 12hrs...

An attending showed me how to use a long cotton tipped swab to get a sample for occult blood. DRE without the digit. Pts seem to like it more than my sausage fingers. Also, at many places they just use the little green rubber stick things (not sure what they are called but around here a lot of PCPs send pts home with them to get a sample.)

Look Im open to learning something new here, but im racking my brain and can't think of a single good reason to do one in the ED or in really any setting. If you think there is a mass, they are gonna get scoped and scanned anyway. The evidence about prostate exams leads me to think they are worthless.

Unless you are breaking up stuck poop, I don't see how they accomplish anything.

An attending showed me how to use a long cotton tipped swab to get a sample for occult blood. DRE without the digit. Pts seem to like it more than my sausage fingers. Also, at many places they just use the little green rubber stick things (not sure what they are called but around here a lot of PCPs send pts home with them to get a sample.)

Look Im open to learning something new here, but im racking my brain and can't think of a single good reason to do one in the ED or in really any setting. If you think there is a mass, they are gonna get scoped and scanned anyway. The evidence about prostate exams leads me to think they are worthless.

Unless you are breaking up stuck poop, I don't see how they accomplish anything.

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I don't know where you are, but our length of stay isn't nearly that bad.

I have little tiny fingers, so patients don't seem to mind. I'd be worried about causing mucosal trauma with a qtip. Sounds like more work than just getting the rectal exam over with. I've never seen any green rubber stick thingies either. I'd happily skip most DREs if I could get the patient to give me a stool sample. You can also check a rectal temp on the patient and get a sample that way.

The only TRUE indication for a DRE in an ER patient in suspected spinal cord inury. to check for rectal tone.

Agree. Very little real utility. I do it when indicated but no nearly as often as others. For example, there is a practice at our place of doing DRE on every patient prior to starting anticoagulation. Insanity. We also still do them on our trauma patients where there is much evidence that they add nothing to the evaluation (and were made optional in the new ATLS for that reason).

I feel the same way about pelvics. The only thing I really care about most of the time is the bimanual, the speculum exam adds little to the "STD check" that is our most common indication.

The physical exam itself is dying a slow death. Most maneuvers taught in medical school have little utility. I highly reccomend JAMA's "The Rational Clinical Examination" series.

Agree. Very little real utility. I do it when indicated but no nearly as often as others. For example, there is a practice at our place of doing DRE on every patient prior to starting anticoagulation. Insanity. We also still do them on our trauma patients where there is much evidence that they add nothing to the evaluation (and were made optional in the new ATLS for that reason).

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A hemmoccult has never changed my management. If they are elderly with "dark stool" epigastric pain, or anemia they need admission and scope, regardless of what a hemmocucult would show. We have some absolutely insane docs who insist on doing them on STEMI patients before starting Heparin or Plavix. Insanity I say!

I feel the same way about pelvics. The only thing I really care about most of the time is the bimanual, the speculum exam adds little to the "STD check" that is our most common indication.

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Agreed with this two. There is no utility on most of the pregnant "spotters" or stable vag bleeder. I'll only do it now for people complaining of serious bleeding, or severe low abdominal pain with no etiology based on the other tests.

The physical exam itself is dying a slow death. Most maneuvers taught in medical school have little utility. I highly reccomend JAMA's "The Rational Clinical Examination" series.

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You mean you don't use Psoas and Obturator signs daily in your clinical practice for belly pain?

Look Im open to learning something new here, but im racking my brain and can't think of a single good reason to do one in the ED or in really any setting. If you think there is a mass, they are gonna get scoped and scanned anyway. The evidence about prostate exams leads me to think they are worthless.

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Now, I agree with the general sentiment that it is an over done exam, and that the old "only two reasons not to do a rectal" line is mostly good for getting the lazy/scared MS3 to do the exam...

BUT

I still think they are useful! Even as a grown up attending, i still do my own rectal exams!

(1) Random old gomer with new/severe anemia: normal stool versus melena is a useful finding!
Yes, yes, I know you are going to admit them anyway, and one day they will have a BM that a nurse could check for you.... but finding that sticky, smelly unexpected melena is a true diagnostic joy which the skittish, squeamish, weak-willed among us will never taste!
(2) Prostatitis: It is real. Hard to diagnosis it otherwise. Man up and poke that prostate!
(3) Peri-anal, peri-rectal, peri-peri abscesses: useful to do a rectal. Or just chicken out and call the surgeon. Your choice. (*bock bock bock* *flaps wings*)
(4) Neuro examination: I would argue it is rare to have low tone be the ONLY finding, but when there are other findings of potential cord injury or cauda equina it is useful. I certainly don't do a rectal on every back pain patient. But maybe I should. No oxycodone without a rectal. We could put signs up!

Now, does every body with a couple blood streaks in their BM HAVE TO HAVE a rectal? Of course not. But I wouldn't fault you for doing one. Same thing for someone with pain during defecation.

Now, I agree with the general sentiment that it is an over done exam, and that the old "only two reasons not to do a rectal" line is mostly good for getting the lazy/scared MS3 to do the exam...

BUT

I still think they are useful! Even as a grown up attending, i still do my own rectal exams!

(1) Random old gomer with new/severe anemia: normal stool versus melena is a useful finding!
Yes, yes, I know you are going to admit them anyway, and one day they will have a BM that a nurse could check for you.... but finding that sticky, smelly unexpected melena is a true diagnostic joy which the skittish, squeamish, weak-willed among us will never taste!
(2) Prostatitis: It is real. Hard to diagnosis it otherwise. Man up and poke that prostate!
(3) Peri-anal, peri-rectal, peri-peri abscesses: useful to do a rectal. Or just chicken out and call the surgeon. Your choice. (*bock bock bock* *flaps wings*)
(4) Neuro examination: I would argue it is rare to have low tone be the ONLY finding, but when there are other findings of potential cord injury or cauda equina it is useful. I certainly don't do a rectal on every back pain patient. But maybe I should. No oxycodone without a rectal. We could put signs up!

Now, does every body with a couple blood streaks in their BM HAVE TO HAVE a rectal? Of course not. But I wouldn't fault you for doing one. Same thing for someone with pain during defecation.

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Agree with the above.

Some might argue that there's no need to do a neuro exam on patients with stroke symptoms, because they're going to get an MRI down the road anyway. There's actually some merit to that argument, but it's not how I want to practice/learn/teach medicine.

I often wonder how many rectal exams attendings would want if they did them themselves!

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Here's how I see it - if the resident has considered the differential diagnosis that the rectal/pelvic/tonopen/whatever will help to rule in or out, and he or she has confidently excluded it based on other evidence, then I am fine with not doing it. I get bent out of shape when a resident or medical student doesn't do an exam, and then when I ask about GI bleed/PID/glaucoma they respond with a blank stare.

So no, not every trauma patient needs a rectal and not every female of child bearing age needs a pelvic. If it wasn't done because your H&P demonstrates that it's clearly not needed - kudos to you. However, if the exam wasn't done because it's gross, or because the diagnosis wasn't considered - then we have a problem.

So yes, attendings may do fewer rectals on their patients than residents. I hope that's because the attendings are better at developing and refining differentials...but I'm not naive enough to think this is always the case.

On a related note, I was walking in to the department the other day thru the parking lot, and was passed by a patient (who was obviously headed to the ED) on his motorized wheelchair. He had a fresh cigarette in his mouth and taking a big drag on his way up to the front doors/triage area.

Never let anyone tell you that EM isn't glamorous. I do rectals on most GI bleeds that aren't complaining of bright red blood because if they don't have melena and their labs look reasonable then I usually dc with GI f/u. If they do have melena then I usually send a guiaic because I have a couple of GI consultants that are convinced that every patient with black stool just chugged a bottle of Pepto and isn't really bleeding.

Aside from what Janders mentioned, I think you should stick a finger in baby butts looking for NEC, late intussusception, malrotation, etc. You might be able to wait for a hemoccult from other source, but I'd rather not.
And also: Rectal foreign body.

I'm also afraid of looking silly on the phone if I call to admit an anemic patient and haven't ruled out that source. It's something that you're not likely to run into trouble for doing (Only case I can think of is neutropenic fever) but has the potential to burn you if you are unlucky. Basically, I kind of believe the classic EM mantra of CYA by doing things that others might forget or otherwise be to lazy to do later on.